Provider Demographics
NPI:1417946179
Name:MITRA, AVIJIT (MD)
Entity Type:Individual
Prefix:
First Name:AVIJIT
Middle Name:
Last Name:MITRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MASONIC AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3048
Mailing Address - Country:US
Mailing Address - Phone:203-265-5720
Mailing Address - Fax:203-679-5623
Practice Address - Street 1:22 MASONIC AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-3048
Practice Address - Country:US
Practice Address - Phone:203-265-5720
Practice Address - Fax:203-679-5623
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT0394502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001394501Medicaid
H72596Medicare UPIN
CT001394501Medicaid